A number of research articles suggest that women are more susceptible to mild Traumatic Brain Injury. In fact, female college athletes have a higher rate of concussion compared to males when playing soccer (2.1 x greater risk), softball versus baseball (up to 3.2 x greater risk), and basketball (up to 1.7 x greater risk). So, why the difference? Research and anecdotal evidence has turned up three possible reasons: cultural differences; hormonal differences, or physiological differences.

Canada forward Christine Sinclair (right) and USA midfielder Carli Lloyd head the ball during the 2016 CONCACAF women’s Olympic soccer tournament at BBVA Compass Stadium in Huston, Texas, on February 21. Soccer is also among those sports programs that produce a large share of concussions for female athletes. — Reuters

Some experts have said part of the reason for increased concussions in females may be due to the reporting rate — that women are more likely than men to notify a coach they are injured, whether due to a head injury or other concern. Cultural differences indeed indicate a reluctance among males to report any injuries for fear of being removed from play. However, because of the very nature of concussion being a clinical diagnosis that usually depends on self reporting, it is hard to say that the incidence differences between the genders is due to honesty.

Other research suggests that hormones including estrogen, oxytocin, progesterone, and testosterone, affect recovery times from concussion. Of course, men and women have vastly differing levels of these hormones. One published study from the University of Rochester (NY) has also shown that menstrual cycles play a part in healing from head trauma. The research showed that women in child-bearing years experience greater cognitive decline, delayed reaction times, extended periods of depression, more headaches, and longer hospital stays and return-to-work plans compared to men following head injury.

Other research suggest that there are different neuronal connections between the hemispheres and significant lobes within the cerebral cortex for men and women potentially influencing recovery time. A recent Georgetown University Medical Center study showed that mice with a single head injury temporarily lose 10 to 15 percent of the neuronal connections in their brains, which can be repaired when at least a week of rest is provided. The fact that male and female brains are “wired” differently could account for a higher incidence of and/or a longer healing period after brain injury in women.

Realistically, interplay of all of these factors could potentially influence the differences in concussions between the number of concussions of female athletes and their recovery.

CTE’s connection to football has been in the news for five years now, with a debate centered around whether the number of concussions will affect long-term health and well-being of those playing the sport. Likewise, I’m constantly asked by patients and parents what the future effect of this or future concussions will be on their health. A recent study released by researchers at the Boston University School of Medicine (such as Dr. Robert Cantu, Dr. Ann McKee, Chris Nowinski and others) will probably give moms and dads across America a moment of pause before starting a collision sport like football or hockey.

An answer may lie in a concept developed by these researchers called the Cumulative Head Impact Index (CHII). They found individuals who had more hits to their heads—regardless of whether they had a concussion or not, were significantly (i.e., not even close…a large statistic margin) more likely to experience later-life cognitive problems, apathy and depression. The caution here is that the sample size was only 93 individuals and the exposure was only to football.

The next step is for medical providers and concussion specialists to help families begin to connect the dots throughout the developmental hurdles of a child’s life. For example, the health outcomes for two 7th grade beginning hockey players if they have a different history. One student may have fallen off a changing table as an infant and suffered a skull fracture, have been in a motor vehicle accident, and have fallen multiple times during winter sports, while the other 7th grader may not have suffered any head injuries or significant head trauma. Baseline neurocognitive testing like the ImPACT® test might look different on these two young students, and the outcome and recovery time of any current injuries sustained by each of them could be considerably different.

I’ve often said that kids can’t live in a bubble as much as parents are sometimes inclined to want to wrap their kids in bubble wrap. Young people—really, people of all ages—are going to be in car accidents, bike accidents, and slip and fall just going through life. Parents need to make their own unique, informed decision about how much additional risk of physical injury to which they want to expose their child, given his or her medical history and athletic abilities.

A recent Fox Sports article discusses the youth concussion laws that have passed in all 50 states and the District of Columbia, but it also highlights some key elements that were missed.

Over the past five years, each state has modeled their laws after the State of Washington law in 2009, also known as “The Zackery Lystedt Law” after a high school athlete who suffered a life-changing concussion (pictured below, pre-injury and today, with his father).

Unfortunately, only 21 states have implemented all four key components of Washington’s law, which is considered the gold standard by many professionals:

1. REMOVAL FROM PLAYThis is pretty basic. The science and medical reasons for asking a child or athlete to leave a game or practice when a concussion is suspected is in place so a second and potentially more dangerous concussion does not occur. As of today’s writing, neither Illinois nor Wyoming requires the removal of an athlete from play in such a scenario. Arizona and South Carolina allow an athlete to return to play the same day if cleared by a physician.

When a child is suspected of having a concussion, it is a good idea to at least wait 24 to 48 hours after the injury to ensure that symptoms do not develop. Here at HeadFirst, as many as 40% of our patients develop symptoms one to two days after their injury.

2. EDUCATIONFortunately, this is not as opposed as it was just three or four years ago. Coaches now realize the importance of receiving education about how to evaluate and treat a head injury. New York law requires not only coaches but also nurses, athletic trainers, and teachers to receive training on concussion and concussion management.

But New York is the exception and there are many states that don’t require education about concussion. Researchers and scientists also still need to do much in this area. Studies have not been completed on what coaches and athletic trainers know prior to training and what type of training is effective.

3. PARENTAL CONSENTThis is quite a basic component of the law which requires student athletes and parents to sign an informed consent stating they understand the dangers of the sport and that a concussion or traumatic brain injury is one of the risks involved in the sport.

4. MEDICAL CLEARANCEOnly 30 states have this element as part of their laws requiring clearance by a trained concussion healthcare provider prior to injured athletes’ return to play. Many laws and training programs also do not specify what training a concussion specialist needs or requires.

Even though these elements are a good first step, they’re still not enough to protect our children. A carefully designed return-to-learn plan is just as important in concussion recovery since academic demands can slow brain healing. Unfortunately, only two states—Nebraska and Virginia—have return-to-learn elements within their concussion guidelines. These procedures require a school to be notified if a student has sustained a concussion and then to give that student accommodations due to the injury.

Some states have even made unsuccessful attempts to add supplementary requirements to their concussion laws.

Oklahoma tried to add a section to their law that would mandate suspensions and punishments on coaches and athletic trainers who didn’t follow concussion guidelines.

Massachusetts attempted to add required neurocognitive baseline testing for all high school students.

And, Maryland tried to add a requirement of helmet sensors on high schoolers’ helmets before basic scientific research had been completed on the sensors or the meaning of a positive or negative sensor result.

A number research studies continue to suggest the negative effects of alcohol (and other recreational drug use) after brain injury.

Alcohol is a neurotoxin — meaning alcohol kills brain cells — exacerbating the effects of a concussion. There is no recommended safe amount of alcohol or recreational drug use after a concussion. Even moderate amounts of alcohol for people with a concussion have been associated with increased deficits in memory, attention and balance.

Additionally, heavy pre-injury alcohol consumption is associated with poorer health outcomes and substance abuse post-injury. Many concussion patients report they are more sensitive to the effects of alcohol after injury. Even a small amount of alcohol after a concussion can impair judgment and increase the risk of a fall (and subsequent head injury).

There are many brave people in the world but every once in a while you come across someone whose story is so inspiring that you are amazed by their ability to overcome adversity.

Meet Kelley, a courageous young lady who suffers from concussion. After being diagnosed, she made the decision to help educate others about the dangers of concussion and help other people realize they are not alone in their struggle. She has already spoken at schools on the topic of brain injuries, her story was featured in the summer newsletter of the Brain Injury Association of Massachusetts and, now, she has agreed to be a recurring contributor to our blog by posting journal entries about her ongoing saga.

This is Kelley’s Story:

“Ten months ago I sustained my second concussion while playing volleyball on my high school varsity team. Since then I have endured ten months of often excruciating headaches and neck pain. Ten months of home tutoring to help me keep up with my schoolwork because the lights and noises of the school environment are unbearable. Ten months of solitude to wrestle with the fact I may never be able to play the sport I love again. In all of those ten months confined to my home, I am yet to hear any encouraging words from my peers. It made the isolation worse and even harder to deal with. I wondered if other people had a similar story? Was there anyone else out there who is going through, or has gone through, this struggle with this kind of a traumatic brain injury? If I had someone else that was going through the same thing, I think it would be easier to deal with all of the changes in my life that I had no control over. I hope by contributing to this blog, I can encourage others. I hope people who are suffering through this injury know they are not alone, and that there are people who truly understand what they are going through. I also desire that people would read my stories and have a new compassion and understanding for those that they encounter who have been impacted by this silent brain injury.”

This evening at 9pm (EST), NBC Rock Center, hosted by Brian Williams, will report on the staggering numbers of concussions sustained by adolescent girls playing soccer. Female contact sports means concussions are no longer an issue just affecting boys. Read the full article here for more information about tonight’s program. Check out your local listings for the channel.

This week marks National Safe Kids Week, an annual public education event started by Safe Kids Worldwide to help understand and prevent childhood injuries. A national survey sponsored by the organization and corporate giant Johnson & Johnson provides a revealing look at misperceptions in the world of youth sports.

The results of Coaching Our Kids to Fewer Injuries: A Report on Youth Sports Safety show parents and coaches are naïve to serious conditions like overuse injuries, dehydration and concussions.

Some results of the survey:

• 1 in 3 children who play team sports are injured seriously enough to miss practices or games, and some suffer lifelong consequences

• 90 percent of parents underestimate the length of break children should take from playing a sport during the year to protect them from overuse and burnout. According to The American Academy of Pediatrics (AAP) and the American Orthopaedic Society for Sports Medicine (AOSSM), children should take a couple of months, or one season, away from a specific sport each year. Young athletes should also take at least a day off each week from organized activity.

• More than half of all coaches believe there is an acceptable amount of head contact during play, without potentially causing a serious brain injury. The fact remains the degree of impacts are difficult to determine until properly evaluated by a medical professional.

• Almost 50 percent of all coaches indicated they have felt pressure from parents or the athletes, themselves, to keep an injured child in a game.

• 30 percent of children think talented players should keep playing even when they’re hurt, unless a coach or adult makes them stop.

• Three-quarters of coaches report they would like additional training on preventing concussions.

Kate Carr, President and CEO of Safe Kids Worldwide says, “Culturally, there’s an attitude that injuries are a natural consequence of sports and that good athletes tough it out when they suffer an injury. But that attitude is hurting our kids.”

The survey was conducted online in February and March 2012, collecting data from 516 children aged 8 to 18 who played a variety of sports, as well as from 750 parents and 752 coaches.

Steven Broglio, Ph.D., A.T.C., director of the University of Michigan’s Neurotrauma Research Laboratory and assistant professor at the U-M School of Kinesiology, has been conducting research on the number of hits sustained by a high school football player and is reporting staggering numbers.

Using helmet sensors, Broglio found that the average player sustains more than 650 impacts per football season, though some players experience more than 2,000 hits. A concussion will occur with a hit that measures about 90 to 100 g-force, which Broglio reports as a head smashing against a wall at 20mph.

Another interesting note about is his finding that concussions don’t seem to occur as a result of the “snowball” effect—that is, lots of smaller hits don’t equal a concussion. Rather, all it takes to sustain a concussion is a single, solid hit.

Michigan is one of the few states remaining which has not passed youth concussion protection legislation.

Take a look at the video from the University of Michigan News Service to see Broglio’s helmet sensor and how the hits were measured.